NR603 Week 5 - Patient Case Summary

Patient Information:

• Initials: C.B.
• Age: 38 years old
• Gender: Female
• Race: White
• Insurance: Not specified

Subjective:

• Chief Complaint (CC): “Tired all the time.”
• History of Present Illness (HPI): C.B. is a 38-year-old white woman who presents with complaints of increasing fatigue over the past four months. She reports feeling tired throughout the day with a decreased interest in usual activities. She finds herself less able to complete routine tasks and generally feels slowed down. C.B. is sleeping more than she used to, approximately from 9:00 pm to 7:30 am, but despite this increased sleep, she does not feel rested. She does not wake up during the night and does not nap during the day. C.B. denies any recent acute illnesses and does not recall any specific events that could have precipitated her fatigue. She is concerned about her decreased performance in daily activities and the negative feedback she has received from family, friends, and co-workers. Although she feels something is wrong, she cannot specify her concern.
• Additional Risk Factors: Female gender, family history of diabetes, and a personal history of smoking.

Differential Diagnoses:

1. Hypothyroidism, unspecified (ICD-10: E03.9)
   • Rationale: Hypothyroidism is characterized by an underactive thyroid gland, which can lead to symptoms such as weight gain, fatigue, depression, poor concentration, muscle pain, and menstrual irregularities. These symptoms are common in adults, particularly as they age. The diagnosis of hypothyroidism is typically made through the evaluation of patient symptoms and confirmation with laboratory testing, specifically the thyroid-stimulating hormone (TSH) level. If hypothyroidism is confirmed, treatment usually involves thyroid hormone replacement therapy.
2. Chronic Fatigue Syndrome (CFS), unspecified (ICD-10: R53.82)
   • Rationale: Chronic Fatigue Syndrome (CFS) is characterized by severe fatigue lasting longer than six months, accompanied by at least four of the following symptoms: post-exertional malaise, unrefreshing sleep, impaired memory or concentration, muscle pain, polyarthralgia, sore throat, tender lymph nodes, or new headaches. CFS is a clinical diagnosis made based on the patient’s history and exclusion of other possible causes of fatigue. C.B.’s prolonged fatigue and unrefreshing sleep are consistent with CFS, warranting further evaluation.
3. Major Depressive Disorder (MDD), single episode, unspecified (ICD-10: F32.9)
   • Rationale: MDD can present with symptoms such as fatigue, decreased interest in activities (anhedonia), and difficulty completing daily tasks, which C.B. has reported. The fatigue associated with depression often accompanies feelings of worthlessness or guilt, poor concentration, and changes in sleep patterns. A thorough psychiatric evaluation would be necessary to determine if C.B.’s fatigue is linked to depression.

Objective:

• Vital Signs: Not provided.
• General Appearance: Not provided.
• Physical Exam: Not provided.

Assessment:

1. Primary Diagnosis:
   • Hypothyroidism, unspecified (E03.9): The most likely diagnosis given C.B.’s presentation of fatigue, feeling generally slowed, and other potential hypothyroid symptoms. A TSH test is recommended to confirm this diagnosis.
2. Secondary Diagnoses:
   • Chronic Fatigue Syndrome (CFS), unspecified (R53.82): Considered if hypothyroidism is ruled out and the fatigue persists for more than six months with the associated symptoms.
   • Major Depressive Disorder (MDD), single episode, unspecified (F32.9): To be evaluated if hypothyroidism and CFS are ruled out or if additional psychiatric symptoms emerge.

Plan:

Diagnostic Testing:

1. TSH and Free T4 Levels:
   • Rationale: To evaluate thyroid function and confirm or rule out hypothyroidism.
2. Complete Blood Count (CBC):
   • Rationale: To rule out anemia or other hematological conditions contributing to fatigue.
3. Comprehensive Metabolic Panel (CMP):
   • Rationale: To assess overall metabolic function and rule out other potential causes of fatigue, such as liver or kidney dysfunction.
4. PHQ-9 (Patient Health Questionnaire-9):
   • Rationale: A screening tool to evaluate the presence and severity of depression.

National Guidelines:

• American Thyroid Association (ATA) Guidelines: Recommend screening for hypothyroidism in patients with symptoms such as fatigue, weight gain, and depression, particularly in those with risk factors like a family history of thyroid disease.
• Centers for Disease Control and Prevention (CDC) Guidelines for CFS: Recommend a thorough clinical evaluation, including ruling out other causes of fatigue, before diagnosing CFS.
• American Psychiatric Association (APA) Guidelines for Depression: Recommend the use of screening tools like PHQ-9 for early detection and management of depressive symptoms in primary care.

Patient Education:

• Discuss the importance of following through with recommended diagnostic tests to identify the underlying cause of fatigue.
• Educate the patient on the potential symptoms and treatment options for hypothyroidism, CFS, and depression.
• Encourage maintaining a healthy lifestyle, including regular physical activity, a balanced diet, and adequate sleep, while awaiting test results.

Follow-Up:

• Schedule a follow-up visit to review test results and adjust the treatment plan as needed.
• Consider referral to a mental health professional if depression is suspected or if the patient’s symptoms persist despite treatment.

References:

• Gaitonde, D. Y., Rowley, K. D., & Sweeney, L. B. (2012). Hypothyroidism: An update. American Family Physician, 86(3), 244-251.
• American Thyroid Association. (2014). Guidelines for the treatment of hypothyroidism. Retrieved from https://www.thyroid.org/professionals/ata-professional-guidelines/

• Centers for Disease Control and Prevention. (2020). Chronic Fatigue Syndrome: Diagnosis and Management. Retrieved from https://www.cdc.gov/me-cfs/